Students Name: Laryssa Grguric Patient/Clients Initials: J.G.

Date: 2/25/14

ASSESSMENT: Pt comes from a nursing home facility. Pt is non-verbal at this time. Pt can respond by
lip syncing words or nodding his head yes or no. Pt is understanding of his current nutritional care in the
form of TF. Per pts wife pt has declined gradually due to muscular dystrophy. She reports intiation of
ventilator and TF started ~2 years ago. UBW of 200# per pts wife.

Pts age: 57 Male/Female: M Dx: Chronic resp failure with acute resp distress
Medical Problems/PMH: Muscular dystrophy, chronic resp failure, s/p trach, s/p peg, CHF

Ht. Current Wt UBW/%UBW IBW range /%IBW BMI
71 190# 200#/95% 17210%/110% 26.5


Estimated energy needs (note equation used):
Using DBW of 80kg 25-30 kcal/kg: 2000-2400 kcal/daily
Estimated protein needs (note g/kg):
1.3-1.5 g/kg: 104-120 g prot/daily
Other nutrient needs: N/A Fluid needs: 2200 mL (1 ml per 1 kcal)

Diet History (24 recall):
@ NH Facility: Pt receives Jevity 1.5 1600 mL (1920kcal, 102 g pro)

@NUMC Changed TF to: Glucerna 1.2 1800 mL 450 mL @ 225/2 hr q 6 via G tube - providing ~2200
kcal, ~108 g pro. Maintain water flush @ 200 mL q 6.

Evaluation of Diet History (brief, e.g., limited in calcium and vitamin D, consumes ! amount of sugar, etc.)
Pt has been NPO for last 2 years.


Physical Activity (describe patients physical activity): N/A: pt is immobile.
Pt is at increased risk of developing pressure ulcers. Redness on sacrum, coccyx and buttocks noted.

Diet Order: Tube Feed Study reveals 9677 mL delivery over 7 days. TF average ~1434 mL/day providing
~1720 kcal and 86 g pro daily. Therefore, ~86% of kcal needs met and ~83% of pro needs met. Overall,
an average of 80% TF formula delivery was met during the 7 day TF study.

Pertinent lab values (Date, ! or "; why you think it may be high or low)
2/25/14: Na+ 134 (N), K 4.4 (N), Cl 89 ("), Bicarb 38 (!), Glu 108 (!), BUN 34 (!), Creat 0.6 (N)
Hgb 7.8 ("), Hct 26.9 ("), MCV 91.8 (N)

Cl, Bicarb likely related to respiratory acidosis. Glu may be high 2/2 to corticosteroid usage. Low H&H
and normal MCV details anemia of a chronic nature (non-nutritional).
2/24/14: Mg 2.2 (N), Phos 4.2 (N)

Nutritional Risk Factors (GI, chewing/swallowing difficulties, etc.)
Pt is NPO 2/2 to muscular dystrophy causing dysphagia. Pt also ventilator-dependent.
Pt is s/p peg placement and receives TF via G-tube.


Usual Meds or Dietary supplements; implications/pertinent side effects
Meds: Nexium, Colace, Sena, Prinivil, Metoprolol XL, Mylanta, Lasix
Vitamin: Cerovite 15 ml liquid multivitamin

Food allergies: NKFA
Food intolerances: None at this time (NPO, on TF)
Stage of Change: N/A
Other Comments: Pt is tolerating TF well. Pt is tolerating formula change to Glucerna 1.2 from Jevity 1.5.


NUTRITION DIAGNOSIS(ES):

Problem Etiology (related to) Signs and Symptoms (as evidenced by)

P-E-S Statement(s):
Inadequate enteral nutrition infusion related to daily infusion volume not reached as evidenced by 7 day tube
feeding study revealing an average delivery of 1434 mL of Glucerna 1.2 a day indicating suboptimal EN
volume compared to recommendation of 1800 mL/d.


INTERVENTIONS (Food/and/or Nutrient Delivery; Nutrition Education; Nutrition Counseling;
Coordination of Nutrition Care)*

GOALS PLANS
Maintain weight and nutritional status. - Increase TF volume to 2000 mL/d of Glucerna
1.2 (2400 kcal and 120 g protein). Assuming
85% delivery rate, pt will receive 2040 kcal and
102 g protein which will meet pts meets.
- Clear pump and intiate a 72 hr TF study to
determine if needs are being met with increased
TF rate.
Pt will meet his calculated fluid needs of 2.2 L. - Increased TF
- Continued H
2
0 flushes of 200 ml q 6

Using the Evidence Analysis Library evaluate one of your interventions and note the evidence for your
intervention.
In adult patients who are critically ill, what average amount of enteral nutrition (EN) intake actually
delivered is associated with fewer infectious complications?

Conclusion Statement:
2012 Conclusion: Actual delivery of >60% of enteral nutrition (EN) goal within the first week of
hospitalization is associated with fewer infectious complications in critically ill adult patients. (Grade II)
Evidence Summary
A total of three studies were evaluated for this question [three positive quality studies (two randomized
controlled trials (RCTs) and one cohort study)]. A number of studies were excluded due to confounders
(use of parenteral nutrition (PN) or immune-modulating formulas), which may have affected the results
(Source: http://andevidencelibrary.com/evidence.cfm?evidence_summary_id=251480).

This patient has been on TF for ~2 years but since he is experiencing an acute crisis related to respiratory
illness (likely flu: awaiting on test results), continued delivery of >60% of his enteral formula will help
support against further infectious complications while hospitalized.

*For counseling and education or if appropriate for in-patient, include goal for physical activity. Plan
should include an exercise prescription for frequency, intensity, time and type (FITT). N/A

MONITORING: " all that apply

__"__Weight __"__TF _____supplement intake

__"__Labs: Na+, Glu, BUN/Creat, Mg, Phos

Other________________________________________________________________________________